Summary & Overview
Hepatobiliary Diagnostic Procedures with MCC: Inpatient Reimbursement Overview
This Diagnosis-Related Group covers inpatient admissions for diagnostic procedures of the hepatobiliary system, such as endoscopic and radiologic evaluation of the liver, gallbladder, and bile ducts. It reflects higher-severity cases where a major complication or comorbidity increases expected resource use and influences Medicare inpatient payment.
Diagnosis-Related Group Overview
This Diagnosis-Related Group covers inpatient admissions centered on diagnostic procedures of the hepatobiliary system, including procedures such as endoscopic retrograde cholangiopancreatography, biliary drainage, cholangiography, and other invasive diagnostic interventions performed for disorders of the liver, gallbladder, bile ducts, and associated structures. Clinical scenarios commonly grouped here include evaluation of obstructive jaundice, suspected biliary stones, cholangitis, biliary strictures, and preoperative assessment for hepatobiliary surgery.
The Medicare Severity Diagnosis-Related Group assigns cases by clinical similarity and resource use, with separate severity tiers for cases with Major Complication or Comorbidity and those without. This Diagnosis-Related Group specifically represents the higher-severity tier in the hepatobiliary diagnostic procedure family when a qualifying Major Complication or Comorbidity is present, distinguishing it from lower-severity groups that reflect no complication or only a Complication or Comorbidity.
In the Medicare Severity Diagnosis-Related Group grouper, assignment to this code affects inpatient payment by reflecting increased expected resource intensity due to both the procedural complexity and the presence of major comorbid conditions. Accurate coding of the principal diagnosis, secondary diagnoses that qualify as major comorbidities, and the performed diagnostic procedure is essential to ensure correct grouper assignment and appropriate Medicare inpatient reimbursement.
National Payment Rates
Payer mean rates for Diagnosis-Related Group 420 vary meaningfully across the market. Cigna and Aetna report the highest mean rates (Cigna at $57,228.34 and Aetna at $54,850.55), followed by Anthem ($50,712.58) and BUCA ($48,427.31), with Blue Cross Blue Shield showing a notably lower mean of $33,203.03; Medicare’s average payment amount is $28,870.16. This spread indicates that commercial payers generally reimburse well above Medicare for these hepatobiliary diagnostic procedures with Major Complication or Complicity (MCC), though levels differ by payer.
State Payment Rates
State: Alaska1 / 49
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